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Authorization to Disclose
Protected Health Info

Item#HP-M121E

    This form authorizes MDHHS to share a person's protected health information with specific individuals and/or organtizations.

    • Intended Health Department Use Only
    • Weekly order limit of 25 pieces
    • MDHHS Pub-1183 (Rev. Date 05/15)
    • 8.5" x 11" double sided form



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    1 $0.00

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